28 Fla. L. Weekly Supp. 520a
Online Reference: FLWSUPP 2806HUGHInsurance — Personal injury protection — Demand letter — Letter reflecting an amount claimed to be due that exceeded $2500 policy limits applicable where an insured has not been determined to have emergency medical condition was not invalid
DENNIS HUGHES, Plaintiff, v. DIRECT GENERAL INSURANCE COMPANY, Defendant. County Court, 4th Judicial Circuit in and for Duval County, Small Claims Court. Case No. 16-2019-SC-001943, Division CC-A. July 29, 2020. Emmet F. Ferguson, III, Judge. Counsel: Ashley-Britt Hansen, Law Office of D. Scott Craig, LLC, Jacksonville, for Plaintiff. Cameron J. Ringo, for Defendant.
ORDER DENYING DEFENDANT’S MOTIONFOR SUMMARY JUDGMENT
THIS MATTER, having come before this Court on Defendant’s Motion for Summary Judgment on July 7, 2020. Both parties were represented by Counsel. The Court being otherwise duly advised in the premises, the Court finds as follows:
1. This is a claim for Personal Injury Protection (“No-Fault”) benefits arising out of a motor vehicle accident. Plaintiff submitted to Defendant a presuit demand letter (“demand letter”) with an attached itemized statement and a valid Revocation of Assignment of Benefits providing Plaintiff standing to bring forth the instant action.
2. The demand letter accurately stated the total amount billed by Plaintiff’s medical provider Advanced Healthcare Centers and the total amount paid to Advanced ($0.00, due to Defendant’s coverage denial). The demand letter states it is a demand letter in compliance with F.S. §627.736(10) providing the correct claim number, named insured, and date of loss.
3. Up to the filing of the instant lawsuit, Plaintiff has not been diagnosed with an Emergency Medical Condition (“EMC”) pursuant to F.S. §627.736(1)(a)(4) which states:
(1)(a)(4) Reimbursement for services and care provided in subparagraph 1. or subparagraph 2. is limited to $2,500 if a provider listed in subparagraph 1. or subparagraph 2. determines that the injured person did not have an EMC.
4. Defendant asserts that its policy language complies with the Supreme Court’s ruling in Geico Gen. Ins. Co. v. Virtual Imaging Srvcs., 141 So. 3d 147 (Fla. 2013) [38 Fla. L. Weekly S517a], and sufficiently implicates the Florida No-Fault fee schedule of 200% of Medicare B, referenced in the No-Fault statute. Therefore, Defendant itself asserts and acknowledges that the total No-Fault benefits payable should Plaintiff ultimately prevail in this suit, is less than $2,500.
5. Defendant argues F.S. §627.736(1)(a)(4) refers to, and depends on, F.S. §627.736(4)(b) in order to comply with F.S. §627.736(10). However, neither subsection of the Florida No-Fault Law relates to the other. Statutory interpretation mandates that when the language of a statute is clear and unambiguous, and also conveys a “clear and definite” meaning, then the court must not interpret the language in a way that creates a different outcome, or meaning, from the individual subsections. The statute must be given its plain and obvious meaning. See FL Dept. Of Transp. v. Clipper Bay Invest., LLC, 160 So. 3d 858 (Fla. 2015) [40 Fla. L. Weekly S164b].
6. The lack of an EMC is not meant to prevent a medical provider or patient access to courts by creating an additional presuit requirement. The demand letter subsection of the Florida No-Fault Law provides the requirements to file suit, and whether an EMC was rendered is not a requirement contained in F.S. §627.736(10).
7. Litigants with medical bills over $2,500 who are seeking payment up to that amount due to the lack of an EMC diagnosis, but still having to place the exact amount claimed to be due in the demand letter, would be prevented from filing a law suit should Defendant’s position prevail. A due process violation is clearly created when a litigant is prevented from pursuing legal rights. When examining a potential litigant’s burden in complying with a condition precedent to suit, such as the presuit demand letter at issue here, Florida courts are required to construe such requirements so as to not unduly restrict a Florida citizen’s constitutionally guaranteed access to courts. Neurology Partners, PA a/a/o Bray v. State Farm, 22 Fla. L. Weekly Supp. 101b (Fla. Duval Cty. Ct., Judge Scott Mitchell, Aug. 7, 2016).
8. This Court aligns itself with and does not recede from the prior ruling of this Court itself, in accordance with other county court judges of the Fourth Judicial Circuit, who opine that the “exacting” standard of the “exact amount claimed to be due” goes to the itemized bill and not to any calculation made by Plaintiff. The exact amount claimed to be due on the face of the demand letter is not always the amount that is ultimately determined to be payable. N. FL. Chiro. & Rehab. Ctr. a/a/o Forehand v. Geico, Case No.: 16-2018-SC-004911 (Fla. Duval Cty. Ct., Judge Emmet F. Ferguson, III, Feb. 19, 2019) [27 Fla. L. Weekly Supp. 62a]; McGowan Spinal Rehab Center a/a/o Cameron v. State Farm, 22 Fla. L. Weekly Supp. 708a (Fla. Duval Cty. Ct., Judge Brent Shore, Dec. 17, 2014); EBM Internal Medicine a/a/o Dorelien v. State Farm, 19 Fla. L. Weekly Supp. 410a (Fla. Duval Cty. Ct., Judge Gary Flower, Feb 8, 2015); N. FL. Chiro. & Rehab. Ctr. a/a/o Brown v. State Farm, 22 Fla. L. Weekly Supp. 266b (Fla. Duval Cty. Ct., Judge Eleni Derke, dated Aug. 28, 2014); and Silver Consulting Srvc., Inc. a/a/o Whalen v. USAA, 23 Fla. L. Weekly Supp. 549b (Fla. Duval Cty. Ct., Judge Dawn K. Hudson, dated Sept. 24, 2015).
9. Plaintiff has stated the exact amount billed per the itemized ledger on the face of the demand letter, in full compliance with the demand letter presuit requirements. Defendant is in a better position to adjust the claim, and the burden of adjusting claims is on the insurance company, not the patient or the medical provider. Defendant is aware of its total coverage denial in this case, based on Plaintiff’s alleged misrepresentation. The itemized statement and demand letter provides all necessary information for the insurer to adjust the claim and to pay Plaintiff’s billing, or defend its coverage denial via this lawsuit.
10. The question of demand letter validity is “substantial compliance” and not “strict compliance”. F.S. §627.736(10) must not be interpreted in a manner that results in an unreasonable denial of access to courts.
11. Defendant was supplied with an itemized ledger showing the dates of service and CPT Codes billed. Plaintiff demanded the payment it claimed as due, based on the ledger and in compliance with F.S. §627.736(10). Had Plaintiff placed $2,500 in the amount claimed to be due as Defendant alleges should have happened because of the lack of an EMC, then Plaintiff would not have met the underlying requirements of F.S. §627.736(10). Defendant was in the best position to adjust the claim to show that not more than $2,500 was owed in this case, along with the knowledge that an EMC had not been rendered.
ORDERED and ADJUDGED that:
The Defendant’s Motion for Summary Judgement is DENIED.
